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Your autoimmune system is betraying you.
What is Vitiligo?
Vitiligo is a non-contagious autoimmune disease for which there is no known cure. Vitiligo causes localized skin depigmentation resulting in starkly white irregular skin patches (lesions) to randomly appear within healthy darker skin, and it can affect any part of the body including the face, arms, legs, genitals and scalp. Vitiligo affects roughly 1% of the world’s population1 and occurs in all skin types and in all races. With vitiligo, it is believed that an overactive immune system improperly attacks the skin’s pigment producing cells called melanocytes and destroys their ability to produce melanin, the skin’s colorant and its natural protection from sunlight. Vitiligo does not produce pain or itching but without pigment the lesions may be at increased risk of skin cancer.
Although the exact cause for vitiligo is unknown, most theories suggest a genetic predisposition2,3 component combined with external factors such as lifestyle and stress4. Indeed, vitiligo is usually triggered by a stressful event, such as a divorce, job loss, or strong negative impression. Vitiligo can deeply affect the patient’s self-esteem and quality of life, with the white spots often being more disturbing for the patient than for the people around them. In many cases the disease is self-perpetuating, as the vitiligo spots cause further patient stress and further disease progression. Those with darker skin may be more profoundly affected emotionally due to the greater visual contrast between the white patches and their healthy dark skin. In some cultures those with vitiligo are unfairly treated very harshly.
There are Two Types of Vitiligo:
Responds well to UVB-NB Phototherapy
Non-Segmental vitiligo accounts for about 90% of cases and affects both sides of the body somewhat symmetrically, with lesions of similar size and shape appearing on both left and right sides of the body. For example, if a spot develops on the left shoulder, a spot will also likely develop on the right shoulder. If the lesions are close enough to the center of the body, they will merge into a single large lesion. Non-segmental vitiligo usually continues to spread to other skin areas over the years. When repigmented, non-segmental vitiligo may reappear, especially for those under constant stress. Non-segmental vitiligo is somewhat easier to repigment than segmental vitiligo.
Responds well to UVB-NB Phototherapy
Segmental vitiligo accounts for about 10% of cases and affects only either the left or the right side of the body. Sometimes the hair originating in the lesions turns white as well. This type of vitiligo usually spreads quickly over 2 to 6 months and then stops progressing. Segmental vitiligo is relatively difficult to repigment, but if repigmentation can be achieved, it will likely never reappear.
What are the Treatment Options for Vitiligo?
Despite what some dare claim, there is no known cure for vitiligo. There are, however, several treatment options that can stop its progression and promote repigmentation, with full repigmentation possible for many patients. The most common treatment options are:
A low-cost, non-medical solution for vitiligo is to simply mask the affected areas with cosmetics, but that requires daily work, is messy, and does not address the underlying immune system problem, allowing the vitiligo to spread further.
In many cases, the medical treatment of vitiligo starts with topical drugs; that is, immunosuppressant creams or ointments applied directly on “top” of the vitiligo lesions. The most common topical drugs for vitiligo include various strengths of steroids, and the topical calcineurin inhibitors (which are not specifically indicated for vitiligo, but are sometimes used under physician guidance). Often topical drugs start working well but then the skin’s response quickly fades in a process known as “tachyphylaxis”, which leads to ever-larger drug doses and ultimately to frustration for patients and doctors alike5. Furthermore, the topical drugs have potential side effects. For example, prolonged steroid use can cause skin atrophy (thinning of the skin), rosacea, and skin irritation. To improve results, topical drugs are sometimes used in conjunction with UVB-Narrowband phototherapy, but they should be applied only after the light treatment. An exception to this is pseudocatalase, which is applied to the skin first, and then activated using a low-dose of UVB-Narrowband. Pseudocatalase is a special topical cream that decreases hydrogen peroxide levels in the vitiligo lesions.
Photo-chemotherapy or PUVA
Back in the 1970’s a procedure known as PUVA6 was the most effective treatment available for vitiligo, and it is still used sometimes today. PUVA consists of two steps:
1) First photosensitizing the skin using a drug known generically as psoralen, which represents the “chemo” part of the procedure and also the “P” in PUVA. The psoralen can be taken orally in pill form, by soaking the skin in a psoralen bath, or by painting psoralen lotion onto only the vitiligo spots.
2) Once the psoralen has photosensitized the skin, which takes an hour or so, the skin is exposed to a known dose of UVA light (Philips /09), which represents the “photo” part of the procedure and also the “UVA” in PUVA.
Besides being messy and difficult to administer, PUVA has significant short-term and long-term side effects. The short-term side effects include dizziness, nausea, and the need to protect skin and eyes from ultraviolet exposure after treatment, until the psoralen wears off. The long-term side effects include a relatively high risk of skin cancer, so the total number of lifetime treatments is limited. PUVA should not be used for children.
Considered worldwide as the gold standard7 for vitiligo treatment UVB-Narrowband (UVB-NB) phototherapy is a light therapy procedure in which the patient’s skin is exposed only to the wavelengths of ultraviolet light medically studied to be the most beneficial (around 311 nanometers using Philips /01 medical fluorescent lamps), and usually without any drugs. Learn more below.
308 nm Excimer Laser Phototherapy
A close relative to Philips UVB-Narrowband with its 311 nm peak is the 308 nm excimer laser. These lasers have very high UVB light intensity and are useful for spot targeting small vitiligo lesions, but due to their size (typically a one inch square treatment area) they provide very little of the positive systemic effects compared to full-body UVB-Narrowband phototherapy. Excimer lasers are also very expensive and are found in only a few phototherapy clinics. UVB LEDs (light emitting diodes) are another emerging technology, but the cost-per-watt of UVB LEDs is still far more than fluorescent UVB lamps.
Chemical Skin Bleaching
The most radical and last-resort solution for vitiligo is permanent chemical skin depigmentation or “skin bleaching”. This solves the cosmetic problem but leaves the patient with very white skin and virtually no protection from light, forcing the skin to forevermore be protected using clothing and/or sunblock.
How can UVB-Narrowband Phototherapy help?
UVB-Narrowband light therapy promotes vitiligo repigmentation in at least four ways:
Boosts Vitamin D Levels
Increasing the patient’s Vitamin D levels, which is also best achieved by exposing as much skin area as possible to the UVB light.
Stimulates Melanocyte Stem Cells
Within the vitiligo lesions, by stimulating the melanocyte stem cells so that new melanocytes are created.
Stimulates Dormant Melanocytes
Within the vitiligo lesions, by stimulating the atrophied melanocytes so they produce melanin pigment again.
Suppresses Overactive Immune System
A general suppression of the patient’s overactive immune system, which is best achieved by exposing as much skin area as possible to the UVB light (and thus best done using a full body phototherapy device).
The objective for each phototherapy treatment is to take just enough UVB‑Narrowband so that within at least one vitiligo lesion a very mild pink color is observed four to twelve hours after the treatment.
The dose necessary for this is known as the Minimum Erythema Dose or “MED”. If the MED is exceeded, the skin will burn and reduce the treatment’s effectiveness. Once the MED has been established, the same dose is used for all subsequent treatments unless the results after treatment change, in which case the dose is adjusted accordingly. Some areas of the body such as hands and feet typically have a larger MED than other areas of the body, so for best results, after the primary full-body treatment is given, these areas should be targeted for a larger dose by providing extra treatment time to those areas only, for example by taking special body positions as shown.
To determine a new patient’s MED and speed up the treatment schedule, some phototherapy clinics will use a MED patch testing device that allows various UVB-Narrowband doses be delivered to several small skin areas at the same time, and evaluate the results after four to twelve hours. Other clinics and the method preferred for SolRx home phototherapy, is to gradually build up the UVB-Narrowband dose using established treatment protocols (included in the SolRx User’s Manual) until MED is evident. For example, a SolRx 1780UVB-NB has an initial (starting) treatment time of 40 seconds per side with the skin eight to twelve inches from the light bulbs, and for each treatment that does not result in MED, the next treatment time is increased by 10 seconds. The patient is thus eased into the correct MED with minimal risk sunburn or an incorrect initial MED. The same protocol is used regardless of the patient’s primary skin type: light or dark.
For a SolRx 1780UVB-NB the final MED treatment time typically ranges from one to three minutes per side for segmental vitiligo, and two to four minutes per side for non-segmental vitiligo. Treatments are usually taken twice per week, but never on consecutive days. In some cases every second day has proved successful. During treatment the patient must wear the UV protective goggles supplied; unless the eyelids are affected, in which case treatment without goggles can proceed if the eyelids are held closed tightly (eyelid skin is thick enough to block any UV from entering the eye). Also, unless affected, males should cover both their penis and scrotum using a sock. Topical drugs, with the exception of pseudocatalase, should be applied only after UVB-Narrowband treatment to avoid light blockage, adverse skin reactions and possible UV deactivation of the drug. After several weeks of diligent treatments the patient’s MED time will be established and within a few months the first signs of repigmentation will appear in most patients. With patience and consistency many patients can achieve complete repigmentation, but it can take twelve to eighteen months or more, with six-foot high full-body devices proving more successful than smaller devices for the reasons listed above.
During repigmentation, sometimes the surrounding healthy skin further darkens as its melanocytes also respond to the treatments, and especially if they are exposed to natural sunlight, which contains far more of the UVA tanning wavelengths than the beneficial UVB wavelengths. To reduce the resulting contrast between lesion and healthy skin, and to avoid sunburn, UVB-Narrowband phototherapy patients should minimize their exposure to natural sunlight by avoiding the sun or using a sunblock (high-SPF sunscreen). If sunblock is used the skin should be washed the day before phototherapy treatment to ensure it does not block the beneficial UVB-Narrowband light. As treatments continue the contrast between lesion and healthy skin will gradually fade.
After repigmentation, sometimes the opposite happens as the newly repigmented lesions may initially be darker than the surrounding healthy skin, a result of the new melanocytes producing more melanin than the old melanocytes when exposed to the same amount of stimulating UV light. This is normal and the contrast will also gradually fade so that within months of continued treatments the patient’s skin tone will become more well blended.
For an interesting video illustrating the UVB-Narrowband repigmentation process for vitiligo, consider watching this video produced by Clinuvel in Australia:
With UVB-Narrowband light therapy, typically the face and neck are the first areas to respond, followed closely by the rest of the body. The hands and feet are typically the most difficult parts of the body to repigment, especially if the vitiligo is well established. To have the best chance of repigmentation, vitiligo patients should begin vitiligo treatments as soon as possible.
After repigmentation has been achieved, some non-segmental vitiligo patients may have lesions reappear over the coming months or years. To help prevent this, patients should consider ongoing and ideally full-body UVB-Narrowband maintenance treatments at a reduced dose and frequency. Doing so helps to keep the immune system under control and protects the melanocytes from renewed attack, while making large amounts of Vitamin D naturally within the skin.
In practice, UVB-NB phototherapy is effective in hospital and dermatologist phototherapy clinics (of which there are about 1000 in USA, and 100 publically funded in Canada), and equally well in the patient’s home. Hundreds of medical studies have been published – a search on the USA Government’s respected PubMed website for “Narrowband UVB” will return more than 400 listings!
Home UVB-Narrowband phototherapy has proven effective because, even though the devices used are typically smaller and have fewer bulbs than those at the phototherapy clinic, home units use the exact same part numbers of Philips UVB-NB bulbs, so the only practical difference is somewhat longer treatment times to achieve the same dose and the same results. Compared to clinical phototherapy, the convenience of home treatments has many advantages, including great time and travel savings, easier treatment scheduling (fewer missed treatments), privacy, and the ability to continue maintenance treatments after repigmentation is achieved, instead of being discharged by the clinic and letting the vitiligo return. Solarc believes that ongoing UVB-Narrowband treatments are an excellent long-term solution for vitiligo control.
“The gentleman who answered the phone when I called once was great! Based on use from March to December it has improved about 50%… I am so pleased SOMETHING is working. It is easy and chemical free! I am hopeful that one day all the spots will fill in and that I won’t have to use it other than for maintenance. Sure, it’s a great system.”
Tiffany, ON, Canada
References & Links:
7. Vitiligo Support International an international non-profit organization supporting vitiligo patients around the world.
AVRF, The American Vitiligo Foundation
VITFriends Vitiligo Support Group
Vitiligo Friends Make Friends, Share Healing Ideas, Inspire Hope
vitsaf Vitiligo Support and Awareness Foundation